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J. Trig Brown, MD

• Assistant Professor of Medicine

https://medicine.duke.edu/faculty/j-trig-brown-md

Occurring with a frequency of >5 per day tic syndrome) should receive both diagnoses medicine kim leoni buy genuine chloroquine. Prevented absolutely by therapeutic doses of ognition is important symptoms juvenile rheumatoid arthritis cheap chloroquine 250 mg amex, since both disorders require 2 indomethacin treatment 606 treatment syphilis 250 mg chloroquine overnight delivery. During part medications not covered by medicaid cheap 250mg chloroquine fast delivery, but less than half medicine xl3 trusted 250mg chloroquine, of the active time lateral head pain lasting seconds to minutes medicine ball core exercises cheap chloroquine 250mg otc, occurring course of 3. In an adult, oral indomethacin should be used ini tially in a dose of at least 150 mg daily and increased Diagnostic criteria: if necessary up to 225 mg daily. Onset is usually in adulthood, in a saw-tooth pattern although childhood cases are reported. At least one of the following ve cranial auto nomic symptoms or signs, ipsilateral to the pain: 3. At least two bouts lasting from seven days to one year (when untreated) and separated by pain-free 1. Meanwhile, each is classi ed remissions lasting <3 months, for at least one as a separate subtype, described below. Both of the following, ipsilateral to the pain: lateral neuralgiform headache attacks, and criter 1. At least two bouts lasting from seven days to one pain-free periods lasting three months or more. Occurring without a remission period, or with one year without remission, or with remission periods remissions lasting <3 months, for at least one year. Headache is not daily or continuous, but interrupted Diagnostic criteria: (without treatment) by remission periods of! Present for >3 months, with exacerbations of moderate or greater intensity Comment: 3. Headache is daily and continuous for at least one year, without remission periods of! Smaller maintenance doses are of patients have the unremitting subtype from onset. Description: Hemicrania continua characterized by pain that is not continuous but is interrupted by remission Comment: Patients may be coded 3. International Headache Society 2018 46 Cephalalgia 38(1) Probable short-lasting unilateral neuralgiform headache Ekbom K. The second case of chronic paroxysmal mal hemicrania in a young child: Possible relation to hemicrania-tic syndrome [Editorial comment]. Chronic par photophobia or phonophobia in migraine compared oxysmal hemicrania-tic syndrome. Clinical hemicrania: A prospective clinical study of thirty perspectives and a case report. Cluster Headache: Mechanisms ing unilateral neuralgiform headache attacks and Management. Lehrbuch der Nervenkrankheiten des headache course over ten years in 189 patients. Martinez-Salio A, Porta-Etessam J, Perez-Martinez D, Sanahuja J, Vazquez P and Falguera M. What has functional neuroi continua: Ten new cases and a review of the litera maging done for primary headache. Other primary headache disorders causative disorder, both the initial headache diagno sis and the secondary headache diagnosis should be given, provided that there is good evidence that the disorder can cause headache. Headaches with similar characteristics to several of these disorders can be symptomatic of another disorder. Other primary headache disorders, according to ache associated with sexual activity and 4. Appropriate and full investigation (neuroima of the disorders classi ed here occurs for the rst ging, in particular) is mandatory in these cases. When a pre-existing headache with the characteristics of any of the disorders classi ed here becomes Description: Headache precipitated by coughing or other chronic, or is made signi cantly worse (usually mean Valsalva (straining) man uvre, but not by prolonged ing a twofold or greater increase in frequency and/or physical exercise, in the absence of any intracranial severity), in close temporal relation to such a disorder. Other reported causes include spontaneous intracranial hypotension, carotid or vertebrobasilar Coded elsewhere: Exercise-induced migraine is coded diseases, middle cranial fossa or posterior fossa under 1. Diagnostic neuroimaging plays an important role in the search for possible intracranial lesions or Diagnostic criteria: abnormalities. At least two headache episodes ful lling criteria B space-occupying lesions in children, cough headache and C in paediatric patients should be considered symp B. However, one Note: report found one fth of patients with cough seen in a chest medicine clinic had cough headache. There is a signi cant correlation section and reversible cerebral vasoconstriction between the frequency of the cough and the severity syndrome. Associated symptoms such as vertigo, nausea and sleep abnormality have been reported by up to two-thirds of patients with 4. International Headache Society 2018 50 Cephalalgia 38(1) exercise headache is usually precipitated by sustained excitement increases and suddenly becoming intense physically strenuous exercise. Brought on by and occurring only during sexual the pathophysiological mechanisms underlying 4. Either or both of the following: gators believe it is vascular in origin, hypothesizing 1. Lasting from one minute to 24 hours with severe internal jugular venous valve incompetence (70% com intensity and/or up to 72 hours with mild intensity pared with 20% of controls) suggests that intracranial E. Multiple explosive headaches during sexual activ strenuous physical exercise ities should be considered as 6. For further research on this headache type, it is Diagnostic criteria: recommended to include only patients with at least two attacks. Severe head pain ful lling criteria B and C Epidemiological research has further shown that 4. Abrupt onset, reaching maximum intensity in <1 Primary headache associated with sexual activity can minute occur at any sexually active age, is more prevalent in C. Thunderclap headache is frequently associated with should always be related to the frequency of sexual serious vascular intracranial vascular disorders, par activity. Lasting from one minute to 24 hours with thunderclap headache is not a diagnosis that should severe intensity and/or up to 72 hours with mild be made even temporarily. When such headache is attributed Description: Headache following exposure of the unpro uniquely to one of these triggers, it should be coded tected head to a very low environmental temperature. Diagnostic criteria: Description: High-intensity headache of abrupt onset, mimicking that of ruptured cerebral aneurysm, in the A. At least two acute headache episodes ful lling cri absence of any intracranial pathology. Brought on by and occurring only during or tion of an external cold stimulus to the head immediately after a cold stimulus applied exter C. Resolving within 30 minutes after removal of the nally to the head or ingested or inhaled cold stimulus C. Some patients develop intense, short-last ing, stabbing headache midfrontally, although the pain Comment: Codable subforms are 4. Description: Headache resulting from sustained com pression of or traction upon pericranial soft tissues. Description: Short-lasting frontal or temporal pain, which may be intense, induced in susceptible people Comment: 4. Brought on by and occurring immediately after a Description: Headache resulting from sustained com cold stimulus to the palate and/or posterior pha pression of pericranial soft tissues; for example, by a ryngeal wall from ingestion of cold food or drink tight band around the head, hat or helmet, or goggles or inhalation of cold air worn during swimming or diving, without damage to C. Brought on by and occurring within one hour population, especially among those with 1. Resolving within one hour after external compres Headache is frontal or temporal, and most com sion is relieved monly bilateral (but may be lateralized to the side of E. A single headache episode ful lling criteria B and Description: Headache resulting from sustained traction C on pericranial soft tissues, without damage to the scalp. Studies show 80% of stabs last three seconds or less; severity and duration of the external traction. Attack frequency is generally low, with one or a few extends to other areas of the head. In rare cases, stabs occur repetitively over days, and there has been one description of status 4. Brought on by and occurring only during sus area to another, in either the same or the opposite tained external compression of or traction on the hemicranium: in only one-third of patients it has a forehead and/or scalp xed location. Maximal at the compression or traction site area, structural changes at this site and in the distribu D. Resolving within one hour after compression or tion of the a ected cranial nerve must be excluded. Migraine, in which cases the stabs tend to be localized to the site habitually Comment: Codable subforms are 4. Head pain occurring spontaneously as a single needle-in-the-eye syndrome; ophthalmodynia period stab or series of stabs ica; sharp short-lived head pain. Felt exclusively in an area of the scalp, with all of the following four characteristics: Description: Frequently recurring headache attacks 1. Lasting from 15 minutes up to four hours after logic lesions, have been excluded by history, phys waking ical examination and appropriate investigations. Comments: the painful area may be localized in any part of the scalp, but is usually in the parietal region. Distinction from one of the types or subtypes of Pain intensity is generally mild to moderate, but occa 3. Other possible causes of headache developing cases, the disorder has been chronic (present for longer during and causing wakening from sleep should be than three months), but cases have also been described ruled out, with particular attention given to sleep with durations of seconds, minutes, hours or days. Distinct and clearly remembered onset, with pain years, but may occur in younger people. Most cases are persistent, with daily or near daily headaches, but an episodic subtype (on <15 days/ Notes: month) may occur. Recurrent headache attacks ful lling criteria B headache may also be ful lled, the default diagnosis and C is 4. Description: Persistent headache, daily from its onset, which is clearly remembered. The pain lacks character istic features, and may be migraine-like or tension-type Comment: 4. Persistent headache ful lling criteria B and C Incompetence of internal jugular valve in patients B. Distinct and clearly remembered onset, with pain with primary exertional headache: a risk factor Benign exertional headache/benign sexual headache: a disorder of myogenic cerebrovascular autoregula Bibliography tion Clinical features Vaga study of headache epidemi Headaches precipitated by cough, prolonged exer ology. Headache asso ciated exertional, cough and sneeze headache respon ciated with sexual activity: demography, clinical fea sive to medical therapy. Follow-up of ciated with sexual activity: prognosis and treatment idiopathic thunderclap headache in general practice. Recurrent thunderclap imaging ndings and outcomes of headache asso headache associated with reversible intracerebral ciated with sexual activity.

Seemingly insignificant forces can cause serious internal injury; therefore abdominal pain after trauma should be taken seriously b medications similar to cymbalta buy chloroquine in united states online. Growth plates generally disappear 2 years after girls have their first periods; in boys it is usually by mid to late high school 5 medicine 230 purchase chloroquine canada. Angle slightly away from the growth plate when inserting an intraosseous needle F medications that cause tinnitus buy chloroquine no prescription. Higher oxygen demand with less reserves means that hypoxia develops rapidly with apnea or ineffective bagging b treatment arthritis purchase 250 mg chloroquine mastercard. When ventilating a pediatric patient treatment centers of america cheap chloroquine 250mg with mastercard, the bag should have no less than 450-500 mL volume c treatment zit order line chloroquine. Err on using a larger bag for ventilating the pediatric patient; regardless of the size of the bag used for ventilation, one should only use enough force to make the chest rise slightly to limit pneumothorax Page 328 of 385 d. Higher oxygen demand and metabolic rate mean that infants and children generally become symptomatic from inhaled toxic exposures prior to adults H. Continually evolves throughout childhood allowing them to develop new abilities 2. The subarachnoid space is relatively smaller offering less cushioning to the brain 4. Brain and spinal cord are less well protected by a thinner skull and spinal column 6. The large cerebral blood flow requirement makes children with head injuries extremely susceptible to hypoxia; hypoxia and hypotension in a child with a head injury can cause ongoing damage as bad as the initial injury itself b. Less cushioning by the subarachnoid space means that head momentum is more likely to result in bruising and damage to the brain c. Cervical spine injuries when present are more commonly ligamentous injuries rather than secondary to broken vertebrae. Since the weaker neck supports a relatively heavier head and therefore flexes more easily with trauma, cervical spine injuries sustained are usually higher (C1-3) f. Infants and children are prone to hypothermia due to increased body surface area 3. Make sure to cover the head (not the face, though) to minimize heat loss Page 329 of 385 c. Have a very low threshold for checking blood glucose levels, especially in children who are having a seizure or are lethargic on your exam d. Infants have a relatively large surface area which predisposes them to hypothermia b. When obvious reasons for crying have been addressed, persistent crying can be a sign of significant illness c. Infants of this age whose crying is responded to timely by parents have been shown to cry less at 1 year and have decreased aggression at 2 d. Though infants sleep a lot, they should be arousable; inability to arouse a baby should be considered an emergency iii. Be diligent about keeping babies warm and dry to limit hypothermia Page 330 of 385 iv. Infants do not develop head control until closer to 6 months, so when handling a baby, make sure to support the head and neck well v. This is a particularly stressful time for parents adjusting to the eating, sleeping, and crying cycle; sometimes this is complicated by post-partum depression, too, which can be a risk factor for abuse. Infants do not typically roll until around 3-4 months; a history of an infant less than that rolling himself off of a bed or table and sustaining major injuries may indicate abuse iii. Infants of this age begin to identify and respond to facial expressions; approach them with a smile or funny face and a happy, soft spoken voice iv. By 6 months, babies should make eye contact; no eye contact in a sick infant could be a sign of significant illness or depressed mental status 3. Infants explore objects with their mouths which greatly increases the risk of foreign body aspiration; do not give children exam gloves to play with iii. With the increased mobility of crawling and walking comes exposure to physical dangers B. The front teeth come in before the molars, which means that children may bite off large pieces of food and then not be able to grind them up before swallowing, increasing the risk of food aspiration; do not give children exam gloves to play with iii. Separation anxiety is best dealt with by keeping the child and parent together as much as possible during evaluation and involving the parent in the treatment if appropriate; if possible, interact first with the parent to build trust with infant Page 332 of 385 iv. Separation anxiety is best dealt with by keeping the child and parent together as much as possible during evaluation and involving the parent in the treatment if appropriate; if possible, interact first with the parent to build trust with infant iv. Allow a child to hold objects of importance to them like a blanket, stuffed animal or doll Page 333 of 385 viii. With the head beginning to grow at a slower rate than the body, children begin no longer requiring shoulder rolls limiting flexion of the neck when bag-valve-mask ventilating or intubating ix. As children begin to relate cause and effect, painful procedures make lasting impressions; be considerate by limiting painful procedures and adequately treating pain 3. The rapid increase in language means they will understand much of what you say if simple terms are used iii. Do not waste time trying to use logic to convince preschoolers; they are concrete thinkers,; avoid frightening or misleading comments vii. Children with chronic illness or disabilities begin to be very self-conscious iii. With patients loosing baby teeth and getting adult teeth, one must be particularly careful when intubating ii. School aged children can understand simple explanations for illness and treatments iii. Reassure children that everything is going to be all right, if appropriate, and that they are not going to die vi. Relationships generally transition from mostly same sex ones to those with the opposite sex d. History (age, preceding symptoms, choking episode, underlying disease, sick contacts, prematurity) b. Physical findings (mental status, respiratory rate, pulse oximetry, capnometry, work of breathing, color, heart rate, degree of aeration, presence of stridor or wheeze) 4. Chronic lung disease that usually occurs in infants form born prematurely and treated with positive pressure ventilation and high oxygen concentrations b. Recurrent respiratory infections and exercise induced bronchospasm are complications c. Inhaled medicationsbronchodilators (albuterol, ipratropium, racemic epinephrine) v. Oral and intramuscular medications (prednisolone, dexamethasone)Corticosteroids vi. History (fever, vomiting, diarrhea, urine output, fluid intake, blood loss, allergic symptoms, burns, accidental ingestion) b. Physical findings (heart rate, blood pressure, capillary refill, color, petechiae, mental status, mucous membranes, skin turgor, face/lip/tongue swelling) 4. Anaphylactic: subcutaneous epinephrine, intravenous anti histamines (diphenhydramine, ranitidine), and intravenous steroids d. History (age, sweating while feeding, cyanotic episodes, difficulty breathing, syncope, prior cardiac surgery, poor weight gain) Page 337 of 385 b. Physical findings (heart rate, blood pressure, capillary refill, color, mental status, cardiac murmurs/rubs/gallops, pulse oximetry, 4 extremity blood pressures) c. Causes of altered mental status in children (trauma, toxins, infection, electrolyte or glycemic imbalance, intussusception, seizure, uremia, intracranial bleed, intracranial mass) b. History (age, fever, vomiting, photophobia, headache, prior seizures, extremity shaking, staring episodes, trauma, ataxia, ingestions, oral intake, bloody stool, urine output, baseline developmental level) b. Medications for intubation (thiopental, etomidate, lidocaine, non-depolarizing muscle relaxants) Page 339 of 385 ii. History (polyuria, polydipsia, weight loss, visual changes, poor feeding, abnormal odors, growth delays) b. Physical findings (heart rate, blood pressure, mucous membranes, mental status, virilization, frontal bossing, blindness) c. History (chest pain, weakness, abdominal pain, extremity pain, trauma, bleeding, swollen joints, swollen glands, fever, bruising) Page 340 of 385 b. Physical findings (all vital signs, lung sounds, extremity tenderness, signs of active bleeding, bruises, joint swelling, lympadenopathy, capillary refill) c. History (blood or bile in emesis, diarrhea, age, gender, constipation, fever, medications, tolerance of gastrostomy tube feeds, prematurity, blood type incompatibility, epistaxis, liver disease) Page 341 of 385 b. Physical findings (heart rate, blood pressure, mucous membranes, icterus, capillary refill, blood in nares, abdominal distention or mass, hepatomegaly, pallor, anal fissure) c. School age (infectious enteritis, juvenile polyps, hemolytic uremic syndrome, Henoch Schonlein purpura) iii. History (time of ingestion/exposure, amount ingested, abnormal symptoms, bottles/containers available) b. Specific toxidromes (anticholinergics, cholinergics, opiates, benzodiazepines, sympathomimetics, beta-blockers, calcium channel blockers, salicylate, tricyclic antidepressants) b. Caregiver support Page 343 of 385 Special Patient Population Geriatrics Paramedic Education Standard Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs to formulate a field impression and implement a comprehensive treatment/disposition plan for patients with special needs. Normal changes associated with aging primarily occur due to deterioration of organ systems; B. Pathological changes in the elderly are sometimes difficult to discern from normal aging changes. Reduction in renal function due to decreased blood flow and tubule degeneration 2. May present with only dyspnea, acute confusion (delirium), syncope, weakness or nausea and vomiting B. Peripheral edema is frequently present in elderly patients with or without failure and may signify a variety of conditions 4. Transient reduction in blood flow to the brain due to cardiac output drop for any reason d. Presentation can include dyspnea, congestion, altered mental status, or abdominal pain. Delirium a sudden change in behavior, consciousness, or cognitive processes generally due to a reversible physical ailment. Evaluation of pathophysiology through history, possible risk factors, and current medications. Venous access care should be taken to avoid use of indwelling fistulas or shunt unless necessary in cardiac events. Diffuse tenderness on palpation of abdomen, with distention, guarding, or masses; upon auscultation high pitched noises k. Blood pressures, lying, sitting, and standing noting any change of 10 mm/Hg or more lower as the patient moves to an upright position d. Pulses, lying, sitting, and standing noting any change of 10 beats per minute more higher as the patient moves to an upright position. Chronic Renal Failure is the inability of the kidneys to excrete waste, concentrate urine, or control electrolyte balance in the body. Medications that damage the kidneys: antibiotics, nonsteroidal anti-inflammatory drugs, anticancer drugs 2. Evaluation of patient treatment through reassessment of disease Page 354 of 385 S. Diabetes Mellitus an inability of the pancreas to produce a sufficient amount of insulin causing hyperglycemia. Hyperglycemia: plasma levels greater than 200 mg/dl, fasting levels of greater than 126 mg/dl iii. Diaphoresis, pale skin, poor skin turgor; pale, dry, oral mucosa, furrowed tongue iii. This causes the cells to burn fat, which causes the body to create ketones and ketoacids. Warm, flushed skin, (even though the patient can be hypothermic) poor skin turgor; pale, dry, oral mucosa, furrowed tongue iii. Warm, flushed skin, poor skin turgor; pale, dry, oral mucosa, furrowed tongue iii. Hypothyroidism-is destruction of the thyroid tissue over time that causes an insufficient amount of thyroid hormone in the blood. Myxedema coma is a premorbid consequence of hypothyroidism in the elderly caused by a recent history of surgery, hypothermia, infection, hypoglycemia, and sedative use.

The gut developed embryologically from midline structures and hence pain is generally referred to the midline symptoms endometriosis buy chloroquine 250mg with visa. Fore-gut structures (oesophagus to second part of duodenum) usually give rise to pain in the upper abdomen shinee symptoms mp3 purchase chloroquine with mastercard, mid-gut structures (second part of duodenum to transverse colon) give rise to pain in the middle of the abdomen 2 medications that help control bleeding buy chloroquine without a prescription, and hind-gut struc tures give rise to pain in the lower abdomen medicine reminder alarm order chloroquine 250 mg on line. In contrast to vis ceral pain medications lisinopril buy chloroquine from india, the parietal peritoneum is innervated by somatic nerves and hence pain is accurately localised to the site of inflammation medications borderline personality disorder generic 250mg chloroquine with visa. This type of pain is typically worse with movement, coughing or inspiration and the Acute Abdomen 167 therefore the patient lies still with shallow breaths (unlike colicky pain, where he moves about to try to get comfortable). There appears to be some difference in opinion as to the true definition of guarding and rigidity; however, most surgeons would agree that guarding is an involun tary (reflex) contraction of the abdominal muscles when the examining hand presses down over the inflamed area. It is sometimes difficult to dif ferentiate true guarding from voluntary guarding, where the patient con tracts his own abdominal muscles in anticipation of pain (especially seen in children). However, if you palpate the two sides of the abdomen at the same time while distracting the patient, you may find that the muscles appear tense on one side compared to the other. It is not really possible to do this voluntarily (where the two sides contract symmetrically) and hence this must be true guarding. If peritonitis involves the whole abdomen, then the patient would typically present with a boardlike, rigid, tender abdomen with absent bowel sounds. In particular, attention should be paid to signs of shock or dehy dration as manifested by peripheral shut-down, clamminess, pallor, tachy cardia and hypotension. Introduce yourself to the patient, ask if he minds your examining him and if he has any pain. On inspection of the abdomen (from the foot of the bed) observe for any obvious scars or masses, distension and the movement with respiration. You may find it easier in an exam situation to 168 Surgical Talk: Revision in Surgery comment on your observations as you go along (unless you are confi dent you can present it all at the end). It is sometimes difficult to differ entiate fat from distension (which can be due to flatus or fluid or foetus or faeces). Starting at the furthest point from where he tells you the pain is, gently feel in each of these regions. This gives you a quick idea of any obvious masses or tender areas and whether the abdomen is soft. Next you can palpate a little deeper to build up on the findings of gentle palpation. Rebound tenderness (most painful when the examining hand is removed) is not a good test, as it often causes the patient unnecessary pain and can give equivocal results. Tenderness on percussion is a more accurate and kinder way of assessing the same thing. Examine the liver and spleen (starting in the right iliac fossa for both, with the patient inspiring each time you press in). Always finish your examination by palpating for an abdominal aortic aneurysm and check the hernial orifices and scrotum. A rectal examina tion is mandatory (although in an exam you usually just state that you would like to do it). The breast is really part of the abdominal examina tion, since if you were shown a case of ascites in the exam and you did not comment on the mastectomy scar, you would not receive any bonus points! T h e b o x e s c o n t a i n t h e p o s s i b l e d i a g n o s e s o f p a i n i n t h e s e r e g i o n s. Instead, most patients tend to present with a variety of vague symptoms and signs that do not point to any specific diagnosis. The acute abdomen is the best topic for highlighting this fact, because a patient who presents with epigastric pain and vomiting could be having pancreatitis, cholecys titis, a perforated peptic ulcer or just gastritis, and it may not be possible to differentiate on the history alone. The examination and simple investi gations add further clues to help make a diagnosis, but still it may not be possible to make an absolute diagnosis initially and management may consist of simple treatment such as resuscitation, analgesia and a period of observation whilst further investigations are performed. In other cases, although a specific diagnosis is not made, exploratory laparotomy may be needed. As a student, making the wrong diagnosis is not that important, because there will always be a doctor available to correct you. Performing an appendicectomy on a patient with mesenteric 172 Surgical Talk: Revision in Surgery adenitis is unlikely to be life-threatening; on the other hand, if you make a diagnosis of acute appendicitis in a female with right-sided pain without first performing a pregnancy test, then the surgeon may be left with an appendicectomy incision to deal with an ectopic pregnancy. For example, let us say a 14-year-old girl presents with right iliac fossa pain and nausea. You should, therefore, ask not only the pertinent questions that point to a specific diagnosis but also the questions that will rule out the other diag noses. Thus, note the menstrual history and the history of the pain; for example, the pain of appendicitis usually starts centrally and moves to the right side after a few hours, whereas a torsion of an ovarian cyst gives a sudden onset of right iliac fossa pain. Next, you derive further clues from the examination, looking for localised right iliac fossa tenderness or peritonism. A pregnancy test and urine dipstix and urgent microscopy must be performed to rule out an infection. A sim ple blood test such as a white cell count may help (although it is not that specific), and plain X-rays may give further clues (although not that help ful in this case, they would be if renal stones or bowel obstruction were on the differential). At this point you may have narrowed the differential down to appen dicitis, mesenteric adenitis or a gynaecological problem, but you still may not be exactly sure which it is. If the pain and tenderness appear to settle, no further treatment may be necessary. However, if they persist, then it may be necessary to investigate the patient further. An ultrasound can be helpful, as it can visualise the ovaries and look for any free fluid. In this situation an ultrasound is very sensitive although not that specific, and even if it shows no abormality it does not rule out appendicitis. Another option is to perform a diagnostic laparoscopy where the organs are visualised directly via a laparascope. If the appen dix is inflamed it could be removed laparascopically (if the surgeon has the Acute Abdomen 173 Figure 9. In a male with the same history, symptoms and signs there is not much else it can be apart from appendicitis and mesenteric adenitis, and if the pain did not settle after a period of observation many surgeons would agree that an appendicectomy was indicated without any further investigation. If you are asked to write an essay on the acute abdomen, remember that whilst there are many causes of acute abdominal pain, most are relatively rare. Try to weight your answers to give the most prominence to the more common diagnoses. Breast cancer is very topical and frequently comes up in essays, vivas and long cases. Examination is difficult because it takes a lot of effort to make the patient, who will undoubtedly be anxious, feel at ease. You may be even more nervous or embarrassed than the patient, so always have a female colleague to chaperone you. Inspection Ask the patient to sit on the side of the bed exposing the upper half of her body. With her arms relaxed at her side, observe for any obvious asymmetry or masses, skin dim pling, previous scars and inversion or eczema of the nipple. Then, ask her to raise her arms straight above her head; this strains the ligaments of Astley Cooper and may result in a skin dimple or inversion of the nipple if there is a breast cancer present. Check that pectoralis major is contracted and ask her to relax and contract whilst observing the breast for dimples and inversion of the nipple. This spreads 175 176 Surgical Talk: Revision in Surgery the breast tissue over the chest wall and makes it easier to examine the breast, particularly if it is large. The breast is divided into five areas: the four quadrants and a central nipple area. Remember that the upper outer quadrant which includes the axillary tail is the commonest site for malignancies and that the breast extends from the second rib to the inframammary fold. If you find a lump, note its site, size (by measuring it with your ruler), shape, colour, contour, consistency, temperature, tenderness, tethering, transilluminance, etc. To assess if the lump is tethered more deeply, ask the patient to place her hands on her hips and push inwards. If the patient complains of a discharge from the nipple ask her to demonstrate it. Note the colour and viscosity of the fluid and whether it comes from one or more ducts. Pectoralis major and latissimus dorsi need to be relaxed to allow proper examination of the axilla, so take her wrist, insert your fingers into the axilla (be gentle) and force her arm to her side. Now palpate the axil lary fat pad against the chest wall and note any palpable lymph nodes. It is mobile and not attached to the skin or underlying muscle and it is not tender. The order in which you give this differential diagnosis depends on the age of the patient and your findings. The risk of developing breast cancer by the age of 50 is 1 in 50, by age 65, 1 in 17 and by age 85, 1 in 9. The incidence of breast cancer increases with increasing age and has increased with the introduction of mammographic screening. Overall, only 15% of women with breast cancer have an identifiable risk factor apart from age and gender, which are of course the major factors. Male breast cancer does occur but is much rarer, accounting for about 1 per 300 breast cancers. Overall, if a first-degree relative has breast cancer, then a woman has (a) (b) Figure 10. This risk is increased if the relative had breast cancer at an early age (50) or had bilateral breast cancer at any age. In other words, you may inherit the gene from your father or mother, yet you or your mother may never get breast cancer. Exposure to Oestrogens In general, the greater the number of menstrual cycles and the later those cycles are interrupted by a pregnancy, the greater the risk. Thus, a late menarche, an early menopause (or ovariectomy), pregnancy at a young age and increased parity protect against breast cancer. Pregnancy after the age of 35 is associated with an increased risk compared to nulliparity. There is currently considerable Breast Surgery 179 doubt about whether it should be prescribed to prevent osteoporosis or heart disease. Previous Benign Breast Disease Fibroadenomas and most types of benign breast disease are not a risk factor. Atypical epithelial hyperplasia on breast biopsy, particularly with a positive family history does, however, increase the risk of breast cancer. Other Factors Breast cancer has a low incidence in the Far East and Eastern Europe. The source of oestro gens in these women is the peripheral aromatisation of androgens produced by the adrenal glands. High socioeconomic group, a diet high in saturated fats and high alcohol intake are also linked with an increased risk of breast cancer. Smoking does not seem to be a risk factor and finally lactation probably protects against breast cancer. All cases of breast cancer should be reviewed at a weekly meeting of the team and a management plan dis cussed for each case. The radiology results are ready the same day and the majority of women leave the clinic after a discussion with the surgeon, radiologist and breast care nurse about the likely diagnosis and with a provisional plan of management. In your history you must ask about all of the above risk factors for breast cancer and then obtain a history of the lump (see page 176).

The rst phase pro duces impaired cardiac lling due to impaired venous return as a consequence of elevated intrathoracic pressure treatment brachioradial pruritus purchase 250 mg chloroquine overnight delivery, with a fall in cardiac output and blood pressure medicine names purchase chloroquine 250 mg otc, inducing peripheral vasoconstriction (sympathetic pathways) to maintain blood pressure treatment centers for depression generic chloroquine 250mg on line. The second phase causes a transient overshoot in blood pressure as the restored cardiac output is ejected into a constricted circulation symptoms exhaustion order chloroquine no prescription, followed by re ex slowing of heart rate symptoms rotator cuff tear order line chloroquine. In autonomic (sympathetic) dysfunction treatment statistics purchase 250mg chloroquine mastercard, re ex vasoconstriction, blood pres sure overshoot, and bradycardia do not occur. Cross Reference Orthostatic hypotension Vegetative States the vegetative state is a clinical syndrome in which cognitive function is lost, due to neocortical damage (hence no awareness, response, speech), whilst vegetative (autonomic, respiratory) function is preserved due to intact brainstem centres. Vertigo is often triggered by head movement and there may be associated autonomic features (sweating, pallor, nausea, vomiting). Pathophysiologically, vertigo re ects an asymmetry of signalling anywhere in the central or peripheral vestibular pathways. Peripheral vertigo tends to compen sate rapidly and completely with disappearance of nystagmus after a few days, whereas central lesions compensate slowly and nystagmus persists. A reevaluation of the vestibulo-ocular re ex: new ideas of its purpose, properties, neural substrate, and disorders. This assesses the integrity of rapidly adapting mechanoreceptors (Pacinian corpuscles) and their peripheral and central connections; the former consist of large afferent bres, the latter consist of ascending projections in both the dorsal and lateral columns. Instances of dissociation of vibratory sensibility and proprioception are well rec ognized, for instance the former is usually more impaired with intramedullary myelopathies. Decrease in sensitivity of vibratory perception (increased perceptual thresh old) is the most prominent age-related nding on sensory examination, thought to re ect distal degeneration of sensory axons. Cross References Age-related signs; Myelopathy; Proprioception; Two-point discrimination Visual Agnosia Visual agnosia is a disorder of visual object recognition. The scope of this impairment may vary, some patients being lim ited to a failure to recognize faces (prosopagnosia) or visually presented words (pure alexia, pure word blindness). Visually agnosic patients can recognize objects presented to other sensory modalities. Clinically, apperceptive visual agnosia lies between cortical blindness and associative visual agnosia. Apperceptive visual agnosia results from diffuse posterior brain damage; associative visual agnosia has been reported with lesions in a variety of locations, usually ventral temporal and occipital regions, usually bilateral but occasionally unilateral. A related syndrome which has on occasion been labelled as apperceptive visual agnosia is simultanagnosia, particularly the dorsal variant in which there is inability to recognize more than one object at a time. Visual agnosia: disorders of object recognition and what they tell us about normal vision. There may be dif culty xating static visual stimuli and impaired visual pursuit eye movements. Once contact is made with the hand, the examiner holds up the other hand in a dif ferent part of the eld of vision. Visual disorientation is secondary to , and an inevitable consequence of, the attentional disorder of dorsal simultanagnosia, in which the inability to attend two separate loci leads to impaired localization. Visual disorientation with special reference to lesions of the right cerebral hemisphere. Cross References Simultanagnosia; Visual agnosia Visual Extinction Visual extinction is the failure to respond to a novel or meaningful visual stim ulus on one side when a homologous stimulus is given simultaneously to the contralateral side. Cross References Extinction; Neglect Visual Field Defects Visual elds may be mapped clinically by confrontation testing. The most sen sitive method is to use a small (5 mm) red pin, moreso than a waggling nger. Peripheral elds are tested by moving the target in from the periphery, and the patient asked to indicate when the colour red becomes detectable, not when they 364 Visual Form Agnosia V rst see the pinhead. The central eld may be mapped using the same target presented statically to points within the central eld. The exact pattern of visual eld loss may have localizing value due to the retinotopic arrangement of bres in the visual pathways: any unilateral area of restricted loss implies a prechiasmatic lesion (choroid, retina, optic nerve), although lesions of the anterior calcarine cortex can produce a contralateral monocular temporal crescent. Bilateral homonymous scotomata are postchi asmal in origin; bilateral heteronymous scotomata may be seen with chiasmal lesions. Cross References Altitudinal eld defect; Hemianopia; Junctional scotoma, Junctional scotoma of Traquair; Macula sparing, Macula splitting; Quadrantanopia; Scotoma; Tilted disc Visual Form Agnosia this name has been given to an unusual and a highly selective visual perceptual de cit, characterized by loss of the ability to identify shape and form, although colour and surface detail can still be appreciated, but with striking preserva tion of visuomotor control. The pathophysiology is uncertain but may relate to rhythmic contractions of the cricothyroid and rectus abdominis muscles. With the patient standing, the examiner holds the shoulders and gently shakes backwards and forwards, the two sides out of phase. Normally, the passive arm swing induced by this move ment will be out of phase with the trunk movements, but in rigidity the limbs and trunk tend to move en bloc. Passive swinging of the wrist or elbow joint may also be performed to assess rigidity. Wasting may also be seen in general medical disorders associated with a profound catabolic state. However, this is not a linear scale; grade 4 often becomes subdivided into 4,4,and4+(oreven5) according to the increasing degree of resistance which the examiner must apply to overcome activity. Accepting all these dif cul ties, it should be acknowledged that the grading of weakness, like all clinical observations, is subject to some degree of observer bias. However, there is no evidence that pure lesions of the pyramidal tracts produce this picture: pyramidotomy in the monkey results in a de cit in ne nger movements, but without weakness. Coexistent wasting suggests that muscle weakness is of lower motor neurone origin, especially if acute, although wasting may occur in long-standing upper motor neurone lesions. Weakness with minimal or no mus cle wasting may be non-organic, but may be seen in conditions such as multifocal motor neuropathy with conduction block. Other terms sometimes used for Wernicke-type aphasia are sensory aphasia or posterior aphasia. There may be associated anxiety, with or without agitation and paranoia, and concurrent auditory agnosia. Wernicke placed it in the posterior two-thirds of the superior temporal gyrus and planum temporale (Brodmann area 22), but more recent neuroradio logical studies (structural and functional imaging) suggest that this area may be more associated with the generation of paraphasia, whereas more ventral areas of temporal lobe and angular gyrus (Brodmann areas 37, 39, and 40) may be asso ciated with disturbance of comprehension. A correlation exists between the size of the lesion and the extent of the aphasia. A similar clinical picture may occur with infarcts of the head of the left caudate nucleus and left thalamic nuclei. Cross Reference Tremor Winging of the Scapula Winging of the scapula, or scapula alata, is a failure to hold the medial border of the scapula against the rib cage when pushing forward with the hands. Winging of the scapula may be a consequence of weakness of the serratus anterior muscle, usually due to a neuropathy of the long thoracic nerve of Bell, but sometimes as a consequence of brachial plexus injury or cervical root (C7) injury. Weakness of trapezius, particularly the middle trapezius muscle, may also cause winging of the upper part of the scapula, more prominent on abduction of the arm, when the superior angle of the scapula moves farther from the midline. Witzelsucht Witzelsucht, or the joking malady, refers to excessive and inappropriate face tiousness or jocularity, a term coined in the 1890s for one of the personality changes observed following frontal (especially orbitofrontal) lobe injury. These are most commonly seen in the context of untreated hypothyroidism, but have also been recorded in other situations, including treatment with -blockers, diabetes mellitus, and complete heart block. It may coexist with intermittent voluntary effort, collapsing weakness, cocontraction of agonist and antagonist muscles, and inconsistency in clinical examination. Cross Reference Collapsing weakness Wrist Drop Wrist drop describes a hand hanging in exion due to weakness of wrist extension. When attempting to write, patients may nd they are involuntarily gripping the pen harder, and there may also be involuntary movement at the wrist or in the arm. A tremor may also develop, not to be confused with primary writing tremor in which there is no dystonia.

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